[smbtoolbar]<\/p>\n
Happy Physical Therapy Month to All!<\/strong><\/em><\/p>\n We celebrate PT Month with our first HeFreak Says, SheFreak Says article. We have been talking about creating one in the past year. Then came the first publications from the PT Related Child Outcomes in the Schools (PT COUNTS) study (<\/span>Chiarello et al, 2016<\/span><\/a> and <\/span>Effgen et al, 2016)<\/span><\/a>; which we think give a great opportunity for each of us to come up with our own Top Takeaways and start a dialogue.<\/span><\/p>\n So how does this work? Separately, we each came up with our Top 5 Takeaways (which would explain 2 overlaps), providing commentary and application for each. Then we exchanged notes and provided our takes on each other\u2019s takeaways and commentaries. We hope this inspires all of you SeekFreaks out there to add your comments and\/or insights! <\/span><\/p>\n Although the study is focused on PT, we intentionally made this article beneficial to OTs and SLPs, as well. We summarize the article with our combined Top 5 Lessons for school-based OTs, PTs and SLPs. <\/span><\/p>\n We start with what SheFreak says.<\/span><\/p>\n ~~~~~~~~~~ 0 ~~~~~~~~~~<\/span><\/i><\/p>\n This research is very welcome as it directly examines student outcomes at school. This is the primary way physical therapists demonstrate their expertise and value to the IEP team. It also provides direct evidence to inform school-based practice!<\/span><\/p>\n SheFreak’s 1st Takeaway: School-based PT interventions are effective for student goal achievement.<\/i><\/b><\/span><\/p>\n The GMFCS level of the student and diagnoses had NO effect on the student\u2019s goal attainment!! Does this mean we are effective across varied levels of involvement or are we writing individualized goals well or are we not setting the goals high enough? This can mean many things\u2026<\/span><\/p>\n Application:<\/span><\/i><\/p>\n HeFreak says:<\/b><\/span> I expected that we would both champion this point…it is PT month after all, so why not celebrate! I\u2019m glad you picked out the finding that the GMFCS level and diagnoses of the students in the study had no effect on goal attainment. This may mean that the PTs are able to take into consideration student\u2019s strengths and needs in creating realistic goals. Kudos to the participants in utilizing Goal Attainment Scales effectively! I call for more use of Goal Attainment Scales in our practice. <\/span><\/p>\n SheFreak’s 2nd Takeaway: School-based PTs are not writing goals for generalizing skills.<\/i><\/b><\/span><\/p>\n Why not? If the skills is not generalized or mastered in various settings, the expertise of a school-based therapist is still needed! Are we delegating this critical point to educational staff?<\/span><\/p>\n Application:<\/span><\/i><\/p>\n HeFreak says:<\/span> <\/b>I am actually curious to know how the authors would have classified a student\u2019s GAS as generalization. <\/span>Gordon and Magill in <\/span>Physical Therapy for Children<\/span><\/i> by Campbell, et al (2011)<\/span> describes generalization as the transfer of learning from the \u201cclinic\u201d into the client\u2019s everyday world. For example, being able to transfer from the wheelchair to a commode in a new restroom during a class trip or an unfamiliar restroom within the same school, after much practice using a familiar restroom close to the classroom. This sounds like a great +1 or +2 goal (greater than expected outcome and much greater than expected outcome, respectively). For a child with great potential for improvement, It can even be your 0 (expected outcome). Try it out next time you use GAS.<\/span><\/p>\n Picking up on SheFreak\u2019s question about delegating, we need to discern when to provide direct intervention, and when to delegate. When providing direct intervention, introduce variety by practicing in different environment (variety helps transfers of skills as discussed in the SeekFreaks article on motor learning: Motoropoly – Part 2<\/a>). <\/span><\/p>\n When delegating, be intentional. The great thing is that teachers and classroom staff are with the student for most of the school day, so they can be there when natural opportunities occur to practice a skill. As Gordon and Magill (referenced above) stated generalization \u201cwould occur when all the characteristics of everyday living environment are included in the intervention strategies, wherever they take place.\u201d<\/span><\/p>\n When delegating, school-based therapists should educate and troubleshoot with teachers and classroom staff how to elicit practice of the same skill in different contexts (such as the example of toileting above). Encourage them to not just provide support to the student during novel situations, but also to ask the student questions so that he\/she can develop problem solving skills. <\/span><\/p>\n SheFreak’s 3rd Takeaway: School-based PTs are providing more interventions within school routines than previously reported.<\/i><\/b><\/span><\/p>\n Therapists reported that for 61% of the students, performance of the primary goal behavior was addressed and measured within a school activity or routine. Hooray!! I hope this means we have moved the needle on improving individualization of interventions and decreased our reliance on the pull-out model.<\/span><\/p>\n This is not in agreement with previous reports of school-based PT interventions. Could this be due to the sampling of this study? School-based PTs were recruited from the APTA, Section on Pediatrics and volunteered to participate in PT COUNTS. Might their practice not be representative of typical school-based practice?<\/span><\/p>\n Application:<\/span><\/i><\/p>\n HeFreak says:<\/b><\/span> I actually selected this as my 3rd takeaway, so more on my take on this later. Thanks for pointing out that this is an improvement from previous reports. This is progress towards the least restrictive environment, for sure. I like SheFreak’s idea of providing clinical reasoning and data when intervening within the school routine. This way we can explain the intent to a teacher who may be surprised with our presence in the classroom. And the data will help show the effectiveness (or not) of the integrated service we are providing. <\/span><\/p>\n SheFreak’s 4th Takeaway: For our students with significant or multiple disabilities, we should be seeking measures that are sensitive to small change.<\/i><\/b><\/span><\/p>\n We struggle to find applicable, valid measures to assess the performance of our most significantly involved students and students with multiple disabilities. Often the progress we make with students with multiple or severe disability is painstakingly slow and small in effect change. Sometimes we are working to prevent the loss of skills or skill use, not trying to teach new skills. What sensitivity is required to discern the tiny progression or incremental impact of intervention with this population? <\/span><\/p>\n How can we best rate student progress and intervention effectiveness? While this varies from case to case, as the premise of IDEA is individualization and perhaps our evaluations\/assessments should be individualized also to capture small or sub-clinical change.<\/span><\/p>\n For the students we intervene with in public schools, what is a reasonable rate of progress? What is the time frame to afford an intervention to show its effects or appropriate rate of change?<\/span><\/p>\n Which measure can capture what I am working to change with intervention?<\/span><\/p>\n Application:<\/span><\/i><\/p>\n HeFreak says<\/b>: <\/span><\/span>Excellent takeaway! I\u2019m always glad when I hear about better tools and guidance for children with more severe disabilities. While they have the most needs, we seem to have the least number of tools to help them succeed.<\/span><\/p>\n GAS is more individualized. A therapist can take into account the severity of the student\u2019s disabilities to create realistic, and measurable goals. As mentioned earlier, SFA ratings may be too broad. <\/span>Effgen et al (2016)<\/span><\/a> pointed out that one of the assessment\u2019s \u201cleap\u201d in rating is from \u201cinconsistent\u201d to \u201cconsistent\u201d performance. For students with severe disabilities, consistency may not be a \u201crealistic expectation,\u201d putting a ceiling to the student’s rating. <\/span><\/p>\n Should we discontinue using the SFA for students with severe disabilities? I think the SFA is still useful to create a baseline of the student\u2019s ability to function in the school. However, you may need to decrease its use to monitor progress – perhaps to once a year or longer. And make sure to use GAS when creating goals so you can objectively measure the student\u2019s progress. For more ideas and examples in using GAS, read about the APPT\u2019s Fact Sheet on Goal Attainment Scaling, a link of which you can find in our 10 Handy APPT Fact Sheets<\/a>. Though the fact sheet was created by PTs, they are very usable to OTs and SLPs, as well.<\/span><\/p>\n SheFreak’s 5th Takeaway: Always look at the change scores in the context of the standard measurement error.<\/i><\/b><\/span><\/p>\n Attend to the standard deviations in relation to the scoring rubric applied; how close are the? The PT COUNTS sample was primarily students with cerebral palsy. We know how variable this diagnosis presents in functional contexts, in this case, school functional performance. In this study there were large standard deviations, some close to 50% of the SFA criterion score.<\/span><\/p>\n Attend to the standard error of measurement which is different for each of the SFA sub-scales.<\/span><\/p>\n Application:<\/span><\/i><\/p>\n HeFreak Says:<\/span> <\/b>Great points, SheFreak! This reminds us to always read the manual before using a test. Shorter tests, like the 6-Minute Push Test, do not come with manuals. But they are described in research articles. Read them, and learn not just to master the test, but also how to interpret results. They may have norms, or they may even tell you what change in score, time or distance would signify a minimally clinical important difference. By the way, SeekFreaks compiled some of these tests and their source articles (click here for balance<\/a>, walking<\/a> and wheelchair operation tests<\/a>).<\/span><\/p>\n ~~~~~~~~~~ 0 ~~~~~~~~~~<\/em><\/p>\n HeFreak’s 1st Takeaway: School-based PT works!<\/i><\/b><\/span><\/p>\n Students in the study (n=296) on average slightly exceeded their expected goals as measured by Goal Attainment Scaling. So they did not just meet their goals, but also slightly exceeded them.<\/span><\/p>\n Additionally, over 51% of students showed improved participation (beyond estimated measurement errors), using the School Function Assessment (SFA). As you would remember from our discussion of the ICF Domains<\/a>, participation is the pinnacle of successful interventions.<\/span><\/p>\n However, this begs the question about what happened to the 49% whose SFA did not improve? One reason may be that the SFA is not sensitive enough to capture the student\u2019s improvement in participation. The SFA has 6 general ratings for each item under Part I Participation. Although it is a very useful tool to summarize a student\u2019s participation, the 6 ratings may be too broad to demonstrate small improvement.<\/span><\/p>\n Another reason may be that we need to increase our focus on participation. Here are some things to consider:<\/span><\/p>\n SheFreak says:<\/span> <\/b>We both took this message home, but got some different points out of it. While I do hate to hear anything against the SFA, this research really forces some hard questions about the sensitivity of the SFA. I also agree that this may be indicating we need to target our interventions and focus more on participation. I think reviewing the student goals we work on for ICF Domain, active words and then our intervention plans or IEP service delivery for a % of where we are intervening. I would take it one step further and see what data we are collecting for progress monitoring (\u2018how will student progress be monitored\u2026\u2019) and get a % of how many student we collect participation data!<\/span><\/p>\n HeFreak’s 2nd Takeaway: Only 5% of primary goals created by PTs are in the area of self-care.<\/i><\/b><\/span><\/p>\n Therapists in the study were asked to identify the primary goal among all the goals a student has. Only 5% of the identified primary goals fall under self-care. Why does this upset me? Because self-care skills are important for our students to become successful productive citizens.<\/span><\/p>\n Going back to the PT COUNTS study, we know that the students included are not yet involved in transition planning (which typically starts around age 14). But, should we wait until they are 14 to start working on self-care skills? We all know from our discussion of motor learning principles that frequency of practice is important<\/a>. So starting early (i.e., now) means students will have a lot more time to practice and learn from their failures and successes.<\/span><\/p>\n Now that we confirmed the importance of self-care skills, let\u2019s look at the possible reasons why only 5% of primary goals are self-care goals.<\/span><\/p>\nSheFreak\u2019s Top 5 Takeways<\/b><\/span><\/h3>\n
\n
\n
\n
\n
\n
HeFreak\u2019s Top 5 Takeaways<\/b><\/span><\/h3>\n
\n
\n
\n
\n
\n
\n
\n